INNER SOLUTIONS SELF-REFERRAL FORM

Please use for Self Referral or Family / Professional Referring Client

Inner Solutions Self-Referral Form

Please use for Self Referral or Family / Professional Referring Client

Contact Information

Name*

FirstLast

Address*

Street AddressCityProvincePostal Code

Daytime Phone*

Evening Phone

Can we leave Messages?*

Please indicate if we can leave you a *personal* voicemail from Inner Solutions™ at the number provided.

Daytime Phone—Yes

Daytime Phone—No

Evening Phone—Yes

Evening Phone—No

Confidential Email Address*

Personal Information

Date of Birth*

Date Format: MM slash DD slash YYYY

Services Requested*

Please check all that apply.

Psychotherapy / Counselling

Cognitive Behavioural Therapy

Dialectical Behaviour Therapy

Interpersonal Group Therapy

Psychological or Psychoeducational Assessment

Borderline Personality Disorder Seminar

Mindfulness Based Stress Reduction Program (MBSR)

Mindfulness Mediation Group

Consultation

Dietetic Services

General interest / Education

Unsure

Would you expect or wish others to be involved in the sessions with you?

(e.g., parent, spouse, friend)

Yes

No

Maybe

If Yes or Maybe, what is their relationship with you?

(e.g., parent, spouse, friend)

Do you have a Family Doctor?

Yes

No

Do you have a Psychiatrist?

Yes

No

If yes, please provide their name(s)?

(The name of your Doctor or Psychiatrist / Both)

What do you expect to focus on in therapy, if applicable?

This will be discussed in detail in your first session, so you need not be overly specific. The information you provide simply helps determine which therapist would best serve your needs.

Is there anything else that might be helpful for us to know before you come in?

How did you learn about our office?*

Family Doctor / Medical Clinic

Psychiatrist

Emergency Services

A friend or family member

Google Search

Facebook, LinkedIn or Twitter

Captcha

Comments

This field is for validation purposes and should be left unchanged.

About Us

Inner Solutions™ has provided psychotherapy and education services to individuals, groups, and families in Calgary, AB for over 17 years.

We offer a full comprehensive program for all individuals who would want to use DBT; regardless of diagnosis. We serve clients with all levels of emotional dysregulation and we have developed a component to serve people who want long term support to integrate and sustain the application of their new coping strategies.

From individual and group therapy to dietetics, our team is prepared to help with depression, anxiety, borderline personality, and bipolar disorders, ADHD, disordered eating, addiction, and more.